Infant Feeding in Emergencies

Infant Feeding in Emergencies

MARION KELLY

Recent experience of emergency relief operations in middle-income countries has shown that infant feeding issues can greatly complicate attempts to protect infant health. The two main problems are: how to protect and support breastfeeding in communities where it is no longer the norm and how to assist artificially fed infants without exposing them to the dramatically increased risks associated with artificial feeding under disaster conditions. This article explores the underlying issues and makes a number of recommendations for policy and programmes.

The subject of milk for babies and children can arouse strong emotions and the atmos- phere that surrounds emergency relief operations tends to exacerbate this. When disaster strikes a population in which bottle- feeding of infants is common, relief agencies are faced with a dilemma: knowing the benefits of breastfeeding and the damage that artificial feeding can do, they are reluctant to provide milk, but by refusing to do so they risk appearing callous or incompetent.' This article sets out the main issues in infant feeding under emergency conditions and proposes detailed practical guidelines on how to respond when disaster occurs in a population accustomed to artificial feeding.

In settings of poverty, artificial feeding is associated with increases in infant mortality as high as twenty-five fold (UNICEF 1990). In an urban population in a middle- income country, babies receiving no breast milk were found to be at least seven times more likely to require hospitalisation for diarrhoea than babies who were exclusively breastfed (Mahmood et al., 1989). Even in the UK, babies breastfed for the first three

months of life have a significantly reduced risk of gastrointestinal illness (Howie et al., 1990).

Even in circumstances where bottle feeding is not associated with greatly increased mortality under normal conditions, infant feeding methods can become a matter of life or death when disaster strikes. Exposure to pathogens is increased by the crowded and insanitary conditions in which displaced families are often obliged to live, making the artificially fed baby, who lacks access to the unique anti-infective factors in breastmilk, even more vulnerable to disease. When disaster victims cannot obtain safe water, artificial feeds are liable to become contaminated in the presence of preparation; where facilities for sterilisation of feeding bottles are lacking, the danger is compounded by multiplication of pathogens between feeds. These factors greatly increase the bottle-fed baby's proneness to diarrhoea and other potentially fatal infections. Moreover, many disaster victims find they simply cannot obtain enough infant formula to feed their babies adequately, either because they are cut off from markets

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or because they are unable to afford infant formula (as a result of changes in prices andlor incomes). The result is malnutrition, which further increases vulnerability to infection and the risk of mortality.

Clearly, disaster can dramatically increase the risks associated with artificial feeding. But what is the impact of disaster on breastfeeding? This question is explored in the next section, using evidence from Iraq and other countries.

BREASTFEEDING DURING DISASTERS: EVIDENCE FROM IRAQ AND AFRICA

The Gulf War and subsequent events led to public health emergencies in Iraq during 1991. Most of the malnutrition and much of the excess mortality occasioned by these emergencies was associated with bottle feeding (Bloem et al., 1991; Coady, 1991). At the same time, there was considerable pressure from various quarters to distribute infant formula as part of the relief response. A number of Iraqi officials, journalists (Burleigh, 1991) and relief workers claimed that women in Iraq had become unable to breastfeed as a result of malnutrition andlor psychological stress. But these claims do not stand up to closer scrutiny.

Psychological stress can inhibit milk ‘let- down’ (the release of milk from the breast), but does not affect milk production, which is regulated by a different hormone. The effect of psychological stress on let-down can be overcome if the baby continues suckling (Akre, 1989); in Guatemala it was reported that even after a tendying earthquake women were soon able to resume breastfeeding (Solomons and Butte, 1978).

Research in rural Gambia showed that during the first three months of life, breastfed babies exhibited satisfactory growth despite their mothers’ chronically inadequate diets* (Whitehead et al., 1978). More- over, supplementation of these women’s diets, which increased both their energy intakes and their body weights, produced

no improvement in breastmilk output (which was very similar to that of English and Swedish mothers) or breastmilk fat content (Prentice et al., 1980). Researchers in Bangladesh concluded that even among women whose lactation performance wus adversely affected by acute and chronic undernutrition, ’the quality and quantity of milk . . . were remarkably good, with milk amount and energy concentration only modestly less than in better nourished mothers’ (Brown et al., 1986a, p. 918). This was borne out by the finding that during the first four months of life the growth curves of their babies followed the reference norm (Brown et al., 1986b).

Thus the effect of maternal undernutrition on lactation performance now appears to be much less important than had previously been supposed. Moreover, recent experience in Africa suggests that even under famine conditions, women’s ability to breastfeed is remarkably robust.

Following a year of poor to indifferent food production in 1989, many parts of Sudan experienced near-total crop failure at the end of 1990 (Winnubst et al., 1990). In mid-1991, a survey in part of Darfur - one of the most severely drought-affected areas - showed that virtually all households were collecting and eating wild foods, a phenomenon indicative of severe hardship; high rates of malnutrition in children under five were also documented (de Jonge and Shutta, 1991). Nonetheless, in the same area over 90 per cent of children under the age of 12 months were being breastfed (Hassan, 1991).

Clearly, women in Darfur were able to breastfeed despite months of poor diet. Even during 1984-85, when this region was in the grip of the most severe food crisis it had known for 70 years and most families were subsisting on one meal of wild berries a day, mothers continued to breastfeed, and their babies continued to benefit. During this period death rates in children aged 1-4 years went up five-fold, but there was little

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112 Marion Kelly

or no increase in mortality among infants (de Wad, 1989).

A nutritionist who worked in the camp at Korem, Ethiopia3 during the 1983-85 famine recalls that mothers there continued to breastfeed their infants (Tony Nash, personal communication). Families that ended up at Korem had suffered several years of crop failure before migrating there, and food rations were grossly inadequate throughout the lifetime of the camp. In addition to being severely undernourished, people at Korem experienced immense psychological stress. Destitution had obliged them to leave their villages and walk for several days through a mountainous area in which a guerilla war was being waged, to reach the camp; many witnessed the deaths of one or more family members either on the way to Korem or after arrival there. And yet the mothers continued to breastfeed.

Although nothing is known about the quantity or quality of the Korem mothers’ breastmilk, the anthropometric status of their infants and children was well- documented by Save the Children Fund (UK) (Nash, 1986). Within the camp, levels of wasting malnutrition were very high, both in infants under six months of age and in older children (Tony Nash, personal communication). By contrast, under normal conditions in rural Ethiopia, breastfed babies‘ weight curves follow those of the reference population for the first five to six months of life (Wolde-Gebriel, 1988). Although some of the malnutrition in Korem infants might have been caused by infectious diseases, it is quite possible that mothers at Korem had crossed a nutritional threshold beyond which breastmilk volume andlor composition was adversely affected.

In middle-income countries, however, where chronic undernutrition is relatively uncommon, the possibility of lactational impairment due to poor maternal nutrition must be remote, at least in the acute stages of an emergency. Women in Iraq before the

Gulf War must have been at least as well nourished as the average Ethiopian or Sudanese woman in a good agricultural year. And although the war and the embargo made it more difficult for most people in Iraq to obtain food, virtually every household in the country was (as of late 1991) still entitled to purchase, at heavily subsidised prices, basic foods supplying approximately 1400 kilocalories per person per day, leaving only about a third of total food needs to be purchased on the open market. In addition, most households had some assets that they could liquidate, so women in Iraq were neither as destitute nor as hungry as women at Korem.

It could, of course, be argued that because of the Allied bombing, women in Iraq’s main cities were under greater psychological stress than women at Korem. Failure to understand the transience of the effects of psychological stress on breastfeeding could then be adduced to explain the high rates of bottle feeding observed in postwar Iraq. But if large numbers of women did in fact cease breastfeeding because they thought their ability to do so had been compromised by poor diet andlor stress, there ought to have been a sharp drop in the proportion of mothers breastfeeding during 1991. I found no evidence of any such change.

Unpublished data from Ms. N. Sat0 on several hundred children attending health centres in Basrah for vaccination during July-August 1991 show that 58 per cent of clinic attenders less than 6 months old were being breastfed; for those 6-12 months of age the figure was 43 per cent. These values for mid-1991 are only slightly lower than the national averages of 61 per cent and 45 per cent for these age groups in 1988-89 (unpublished data from the Iraq Ministry of Health, 1991). Moreover, it is probable that even before the war the prevalence of breastfeeding in Basrah was somewhat lower than the national average, since artificial feeding has tended to be more

DISASTERS VOLUME 17 NUMBER 2 0 Basil Blackwell Ltd. 1993


common in urban areas (Harfouche, 1982), and Basrah is one of Iraq’s biggest cities,

While in Iraq in October 1991, I was able to discuss infant feeding with Kurdish and Arab mothers at a dozen health centres in urban and rural areas. Thanks to the Iraqi government’s health education programmes, most of these women knew about the nutritional advantages of breastfeeding and understood that breastfeeding helped to prevent diarrhoea and other illnesses. Moreover, their ability to breastfeed was not hindered by the need to return to work, since all women in paid employ- ment are legally entitled to six months maternity leave on full pay, followed by a further six months at half pay.

A large proportion of these mothers, however, were bottle feeding their infants. The overwhelming majority of those who had introduced bottle feeds said they had done so because they didn’t have enough breastmilk. When asked what they thought were the reasons for this lack of milk, most said it was ‘just something that happened’; they didn’t know why. Fewer than 10 per cent of those who had introduced artificial feeds cited psychological stress as their reason for doing so. None attributed it to their own diets being inadequate, although most said they thought maternal diet could affect lactation performance.

These responses echo the findings of more rigorous surveys carried out in Western populations unaffected by disaster: ‘insufficient milk’ was the reason given by more than half of a large sample of British mothers who had begun bottle feeding after an initial period of breastfeeding (Martin, 1978). ‘Insufficient milk’ is not caused by undernutrition or psychological stress, but by unhelpful practices, usually adopted as a consequence of social changes that impede transmission of the knowledge, skills and confidence that women need in order to breastfeed s~ccessfully.~ Breast- feeding is, after all, a complex behaviour pattern that both mother and baby must

learn, and not an instinctive response automatically triggered at birth.

Contrary to what was widely believed, the Gulf War had little impact on women’s ability to breastfeed; what did change was the level of risk associated with artificial feeding. Widely practiced before the war, artificial feeding became much more dangerous in 1991 as a result of displace- ment of families to squalid camps, damage to water and electricity supplies, reduced access to markets and rising prices for imports.

NEED FOR MORE SPECIFIC GUIDELINES

The importance of breastfeeding in times of disaster was highlighted fifteen years ago (Jelliffe and Jelliffe, 1977). Until recently, however, most of the emergency work done by international agencies and NGOs has been in low-income developing countries, where traditional breastfeeding patterns persist. As the great majority of young infants in these countries are predominantly breastfed and hence in little need of additional food, relief programmes have traditionally concentrated on supplying basic foods to cover the needs of older infants, children, adolescents and adults.

Some of the relief agencies provide practical guidelines on infant feeding in their handbooks. All say that mothers should be encouraged to breastfeed; several recommend that feeding bottles be banned, and that young babies without access to breastmilk be given infant formula by cup and spoon (e.g., UNHCR, 1982; UNICEF, 1986; ICRCILRCRCS, 1985; Appleton, 1987). Although these prescriptions can be followed fairly easily by an agency running a therapeutic (‘wet’) feeding centre in a developing country with strong breastfeeding traditions, experience indicates that they may be difficult to implement when food is distributed on a take-home basis in a middle-income country. In the following sections I explore infant feeding policies


114 Marion Kelly

and strategies appropriate to these circumstances.

provide the emotional, social and technical support needed by breastfeeding women.

SUPPORT FOR BREASTFEEDING

Policy

Attitudes to breastfeeding, knowledge of breastfeeding technique, and confidence in breastfeeding ability are the main deter- minants of breastfeeding during emergencies, just as they are under non-emergency conditions. Since the ability to breastfeed is remarkably resistant to the effects of maternal undernutrition and psychological stress, the notion that many mothers who were breastfeeding pre-crisis will need to use breastmilk substitutes once disaster has struck should be rejected by those with responsibility for relief programmes.

But this does not mean that breastfeeding women need no assistance. Relief agencies have traditionally classified preg- nant and lactating women as a vulnerable group to which extra food should be targeted when there is rationing. In disaster- affected communities in which breastfeeding traditions have been undermined, however, it is not enough simply to supplement mothers’ diets. Although psychological stress need not jeopardise lactation, in societies where breastfeeding is no longer universal many new mothers and a proportion of those currently or previously breastfeeding will require reassurance and encouragement, as well as advice on technique, in order to initiate, maintain or re- establish lactation.

Disaster victims’ more general needs for social and emotional support have been recognised (Seaman, 1984) but rarely addressed by relief agencies, which are con- cerned primarily with saving lives. Since, however, the life-saving potential of breastfeeding is at least as great as that of the intravenous drip or the high-energy biscuit, it is imperative that relief agencies help to

Programmes

When responding to disaster in a middle- income country, relief agencies could deploy trained breastfeeding counsellors, or health care staff who have had training in lactation management and community par- ticipation. Together with local ministry of health staff and community leaders, these relief workers could identlfy women within the affected communities who have the knowledge and skills to help others to breastfeed. These women could then be mobilised as breastfeeding facilitators.

It is important that the presence and the role of the breastfeeding facilitators be made known to existing and aspiring breastfeeding mothers, who may need to be encouraged to call upon them for advice. Financial or in-kind remuneration of the facilitators, which would help motivate them and enhance their status in the community, is worth considering. The importance of obtaining the cooperation of local health care workers should not be underestimated; such people usually have the respect of the community, and are therefore well-placed to ’make or break’ programmes instigated by outsiders.

The community-based breastfeeding facilitator could help the new mother to correctly position the baby at the breast, to develop confidence in her ability to breastfeed, and to overcome occasional problems such as engorgement, sore nipples or ’insufficient milk’. Mothers who have stopped breastfeeding and wish to re-lactate could be advised on how to maximise the stimulus to milk production5 and how to prepare and give other feeds safely in the interim before full lactation is re-established (a period ranging from several days to several weeks, depending on the amount of time that has elapsed since breastfeeding was discontinued). The small minority of


Infant Feeding in Emergencies 115

women who might not respond to this regimen could be referred to health workers qualified to prescribe drugs to stimulate lactation.6 Arrangements for wet nursing (breastfeeding by a woman who is not the baby’s mother) or milk banking (collection of expressed breast milk for feeding babies without access to their own mothers’ breastmilk) could also be ~onsidered.~

Providing the kinds of assistance described above would not be expensive, and the benefits of mobilising community- level support for breastfeeding could extend well beyond the time-frame of the emergency. After the crisis has passed the relief agencies involved would be well- placed to work with the development of the affected country to devise ways of protect- ing, supporting and promoting breastfeeding as part of a national health promotion and disaster preparedness strategy. Ensur- ing that a sufficient number of the affected country’s health care staff receive appropriate training in lactation management’ could be a central component of such a strategy.

ASSISTANCE TO FAMILIES OF ARTIFICIALLY FED INFANTS

Policy Issues and Programme Planning

What can be done to help non-breastfeeding mothers who are either unwilling to attempt re-lactation, or in the early stages of the re- lactation process and hence without an adequate milk supply? If less than six months old, the babies of these mothers will need an appropriate breastmilk substitute. Infant formula is an obvious candidate; unless suitably modified, sweetened con- densed milk and dried skimmed milk are unsuitable for young infants. Alternatively, the possibility of preparing breastmilk substitutes on site using relief commodities and locally available fresh foods (Cameron and Hofvander, 1983; Appleton, 1987) could be explored.

Before getting involved in distribution of infant formula, agencies should give careful consideration to the following questions. Is the emergency being exploited by infant formula manufacturers to open up new markets for their products? Will adquate supplies be available when needed? How can distribution be targeted so as to minimise harmful effects? How can hygienic preparation of infant formula be ensured?

The World Health Organization’s Inter- national Code of Marketing of Breast-Milk Substitutes stipulates that distribution of infant formula should not be started unless adequate supplies can be guaranteed for as long as they are needed (WHO, 1981). Although the size of the population in need can change rapidly during an emergency, especially if military or civil conflict is a factor, it is useful to try to estimate at the outset the number of babies likely to need artificial feeding so as to calculate the quantities of infant formula required, bearing in mind that successful pro- breastfeeding activities should reduce the numbers in need as time goes on. Ideally, an agency would obtain an open-ended donor commitment to meet a particular population’s need for infant formula until the crisis is over. Failing this, an agency would need to establish a steady pipeline by securing a sufficient number of one-off donations with firm delivery dates suitably staggered, or by purchasing supplies as needed.

Targeting of Breastmilk Substitutes

Provision of infant formula must be carefully targeted, not only to help minimise the costs of supplying it, but also to limit adverse effects on breastfeeding. Indis- criminate distribution of free infant formula to a disaster-affected population could do a great deal of damage, even if agencies were capable of providing a steady supply of clean water and fuel for sterilisation. The


116 Marion Kelly

danger stems from the fact that international relief operations are the province of the world’s wealthiest and most tech- nologically sophisticated nations. Receiving assistance from these powerful countries may add to the beneficiaries’ admiration of these nations and their products. The superiority falsely ascribed to artificial feeding by many families in middle-income countries would only be enhanced if foreign agencies were to hand out infant formula indiscriminately .9

A better solution might be to give infant formula only to mothers who had aban- doned breastfeeding well before the crisis, and to assist other mothers to resume or continue breastfeeding. The problem with a targeted distribution is how to identdy the correct target group, in view of the likelihood that many mothers who were breastfeeding pre-crisis will say they weren’t when they realise that this claim is ’rewarded’ with a supply of infant formula. Initially, they might intend to trade the free formula, which has a high resale value, for other items needed by the family; in this case no harm would come to the infant, and other family members would benefit from the extra food or other goods they were able to acquire. The likelihood that breastfeeding mothers will experiment with formula once they have received it cannot, however, be discounted (Bergevin et al., 1983); after all, the use of free supplies has long been one of the infant formula industry’s favourite strategies for promoting its products (Palmer, 1988). Since even the occasional artificial feed undermines lactation (by reducing the stimulus to milk production and thereby engendering in the mother the fear that her breastmilk is insufficient), this strategy as it stands is unsatisfactory.

A suitable modification might be to offer the families of all infants under six months old the choice of registering for either a free ration of infant formula or a free sup le- mentary ration of traditional foods.’ In circumstances where the disaster-affected

@!

population as a whole is in need of food relief, this choice of either infant formula or supplementary traditional foods would be offered in addition to a basic family ration, to which all households would be entitled irrespective of the ages of their members.

In order for this self-targeting strategy to work properly, the traditional foods supplement needs to be of equal market value to the infant formula ration, because families will judge the two options in terms of their resale value rather than their nutritional value. Faced with this choice, the families of breastfed infants can be expected to opt for the traditional foods, some or all of which will presumably be consumed by the mother. Mothers opting to re-lactate could be allowed to claim appropriate quantities of both traditional foods and infant formula until their milk supply has been re-established.

Parents of all babies should be urged to begin the process of weaning when the baby is four to six months old. Appropriate quantities of a suitable weaning pre-mix (containing cereal flour, ground legumes and oil) could be provided to all families with infants 4-24 months, after demon- strations of how to mix it with water and cook it into a porridge. Lactating mothers should be encouraged to continue breastfeeding until the end of the second year, and should continue to receive their supplement of traditional foods during this time in order to protect their own nutritional status. From the age of six months to two years, the artificially fed baby’s infant formula ration can be replaced with one of dried whole milk, or dried skimmed milk (DSM) and oil, to provide the equivalent of half a litre of whole milk per day. If circumstances make it unrealistic to expect parents to boil water for reconstitution of dried milk, the milk powder (or DSM plus oil) should be distributed by incorporating it into the porridge pre-mix of the non- breastfed babies, because cooking of the pre-mix, which is necessary in order to



make it digestible, helps to kill pathogens present in the water.

The additional expense involved in providing infant formula, extra food and fuel will obviously add to the cost of the relief programme as a whole. Another dif- ficulty that should not be overlooked is that of security: since infant formula is a valuable and highly fungible commodity, it may also be necessary to adopt stringent measures to prevent thefts during transport and storage. Other problems posed by this scheme are the need to know the babies’ ages, the need to maintain accurate registers of beneficiary household composition (in order to prevent infants being ‘loaned’ to families without babies, to help them quahfy for extra food), and the need to monitor prices of both infant formula and traditional foods in local markets so that the supplementary ration of traditional foods can be adjusted to take account of changes in the terms of trade.

Babies’ ages should be relatively easy to ascertain in middle-income countries, where the majority of births are registered and remembered by parents. Both mainten- ance of beneficiary registers and monitoring of prices will require locally-recruited wolmanpower, but since registration of beneficiaries, supervision of food distribu- tions and monitoring of food prices are done routinely in most relief operations anyway, the amount of extra work involved will not be enormous.

Promoting Hygienic Utilisation of Breastmilk Substitutes

Under emergency conditions, targeting of infant formula is only half the battle. If, as so often happens, there are shortages of clean water and fuel it is also imperative that steps be taken to minimise the risk of con- tamination of feeds. Fortunately, control over the distribution of infant formula gives relief agencies some scope for influencing its utilisation.

Infant formula for distribution during

emergencies should be supplied in packages devoid of brand names, pictures of babies or pictures of feeding bottles. These packages should carry labels printed in the first language of the intended beneficiaries to explain the special dangers of artificial feeding during emergencies and how they can be minimised; for populations in which adult female literacy is less than universal, the same messages should also be conveyed by means of suitable graphics.

Any family claiming infant formula could be required, at the time of registration, to surrender the baby’s feeding bottle in exchange for a small cup (not a covered cup with a spout), which can more easily be kept clean (Philips et al., 1969); the feeding bottles collected could be publicly destroyed in order to call attention to the hazards of using them. At the same time families opting for artificial feeding could be given a beaker marked to show the correct amount of water for a formula feed, together with a scoop of the correct size for measuring the powder.

Families claiming infant formula could be required to attend one or more sessions at which the importance of hygiene is ex- plained, safe preparation of infant formula is demonstrated, and supervised cup feeding (not cup-and-spoon feeding, which is unnecessarily tedious and time-consuming) is practiced. They could also be required to return to the distribution centre with their infants at regular intervals (e.g., fortnightly) in order to collect take-home supplies of formula; this would make it possible for health care staff to monitor the growth of the babies, to detect and treat infections, and to advise on weaning practices at the appropriate age.

Clearly, the strategies outlined above demand a certain amount of expenditure and a great deal of skilled wolmanpower, which is often in critically short supply during emergencies. In many cases agencies will find themselves unable to implement these recommendations in full; in this


118 Marion Kelly

position they should not conclude that just handing out free infant formula is the next best thing. The next best thing would be simply to try to protect, support and promote breastfeeding, and to improve the conditions under which artificial feeding is carried out, while leaving it to local markets to actually supply the infant formula. Such an approach could involve providing lactating women with additional food (and drinking water) and encouraging them to suckle their babies frequently, improving families’ access to fuel and safe water, improving parents’ ability to purchase infant formula, and persuading parents to use cups instead of feeding bottles.

SUMMARY OF RECOMMENDATIONS

Although the feeding of babies and children is a very important issue in relief work, it is one that many relief agencies are ill- equipped to deal with. In order to avoid the very real dangers associated with indiscriminate use of breastmilk substitutes during disasters, agencies with responsibility for child health need to understand the underlying issues in infant feeding, to have clear policies and detailed guidelines on programme design and management, and to make sure that their staff have the knowledge, skills and resources to implement them effectively. Practical recommendations can be summarised under three headings.

Support for Breastfeeding (1) Remember that even during a

disaster, the overwhelming majority of mothers who were breastfeeding before- hand will be able to continue.

(2) Work with community leaders and local health care personnel to identify suitably experienced local women and mobilise them as breastfeeding facilitators, so that they can assist mothers of infants to initiate, establish, maintain or re-establish lactation.

(3) Provide extra food to lactating women

to guard against possible depletion of their nutrient stores.

Assistance to Families of Articially Fed lnfants (1) Do not begin distribution of infant

formula unless artificial feeding was wide- spread before the crisis, and adequate supplies are sure to be available for as long as required.

(2) Use a self-targeting strategy of offering either infant formula or traditional foods of equal market value to families of babies under six months old.

(3) Implement stringent measures to ensure that formula is utilised safely, e.g.:

- print warnings and instructions on the containers in which infant formula is supplied;

- provide fuel for boiling water; - substitute cups for feeding bottles; and - require frequent attendance at distribu-

tion centres so that infant health and growth can be monitored.

(4) Remember that indiscriminate free distribution of infant formula during emergencies can compound existing problems by fostering dependence on an unnecessary product among a population whose ability to use it safely cannot be guaranteed. If unable to implement the measures recom- mended above, do not distribute infant formula.

General Advise all parents of infants aged four

to six months to begin weaning them onto appropriate semi-solid foods. Provide porridge pre-mix for all weanlings, supplementary milk for those who are not breastfed, and a supplement of traditional foods for breastfeeding mothers.

Additional resources, including a considerable amount of skilled labour, will be required to implement the strategies outlined in this paper. This will cost money, of course, but the price of the alternative - which would ultimately be paid in the


Infant Feeding in Emergencies

currency of children’s lives - must surely be unacceptably high.

Fortunately, moves are now afoot (in the UK at least) to professionalise the response to disasters and to increase the speed with which suitably skilled and equipped personnel can be dispatched to the scene of an emergency overseas (Redmond, 1992; Simmons, 1991). Acceptance of the fact that relief interventions cannot succeed without suffiaent funding and appropriately trained personnel should be central to the relief agencies’ current initiatives to professionalise their work and strengthen their response to disasters.

Notes I thank Dr. Nidhal M. Hirmiz for her expert assistance in Iraq. Although they may not share all of the views expressed in this article, I am grateful to Helen Armstrong, Anthony Costello, Margaret Kyenkya-Isabirye, Mary Marlow, Gay Palmer and Patti Rundall for their thought- provoking comments on earlier drafts. 1. For example, an article in a UK newspaper

about the plight of displaced Kurds in northern Iraq criticised UNHCR for its policy of not supplying milk (Hirst, 1991).

2. The average daily energy intakes of the women studied ranged from less than 1500 to almost 2000 kcal, i.e., roughly 25-50 per cent less than the 2750 kcallday recom- mended by WHOlFAO for the first six months of lactation.

3. Korem was the camp where Michael Buerk and Mohammed Amin made the 1984 BBC television news film that alerted the world to the tragedy in Ethiopia and provided the impetus for Band Aid and other humani- tarian efforts. Buerk may not have been guilty of journalistic hyperbole when he described Korem as ’the closest thing to hell on earth‘.

4. In Iraq, breastfeeding for the first two years of life was still the norm a generation ago (Gounelle and Demarchi, 1953; Demarchi et al., 1965; Harfouche, 1982). As in other middle-income countries, however, the process of economic development has been accompanied by social changes, one of

119

which is the ‘medicalisation’ of childbirth and infant feeding. As childbirth moves out of the home and into the hospital, mothers and babies are more likely to be separated during the early hours and days now known to be crucial to the initiation of lactation. On advice from well-meaning but inapprop- riately trained health workers, many mothers adopt damaging practices, such as incorrect positioning of the baby at the breast, restricting the duration or timing of feeds, offering the second breast before the baby has finished the first one, excessive nipple washing, and giving the baby supplementary milk or water (Royal College of Midwives, 1991). Another social change that can undermine breastfeeding is urbanisa- tion, which tends to reduce mothers’ access to traditional sources of support (most notably senior female members of the extended family).

5. See Savage King (1992) for details. 6. For details see Jelliffe and Jelliffe (1977). 7. Because the HIV virus can be transmitted

through human milk, and because wet nursing and milk banking are unacceptable in some cultures, decisions concerning such practices must take account of both cultural sensitivities and prevalence of HIVlAIDS among the population in question.

8. A suitable course is run by the Institute of Child Health in London.

9. British health personnel working in the Kurdish ’safe haven’ (but not involved in distribution of milk) told me that when they tried to explain the hazards of bottle feeding to Kurdish mothers, they expressed scepticism on the grounds that the practice had originated in the West.

10. Where fuel is too scarce locally to expect non-breastfeeding mothers to boil the water used to make up feeds, these rations should also include a supply of fuel. Where water is rationed, all families with infants should be allocated at least one extra litre of water per day.

References Akre, J. (ed) (1989) Infant feeding: the physio-

logical basis. Bulletin of the World Health Organization. Supplement to Volume 67.


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Appleton, J. (1987) Drought Relief in Ethiopia: a practical guide to planning and management of feeding programmes. Save the Children Fund, London.

Bergevin, Y., C. Dougherty and M.S. Kramer (1983) Do infant formula samples shorten the duration of breastfeeding? Lancet 21 May,

Bloem, M.W., S. Farooq and A. Kuttab (1991) Vitamin A deficiency and malnutrition in southern Iraq: rapid assessment report, 14-26 May 1991. Helen Keller InstitutelSave the Children/ UNICEF.

Brown, K.H., N.A. Akhtar, A.D. Robertson and M.G. Ahmed (1986a) Lactational capacity of marginally nourished mothers: relationships between maternal nutritional status and quantity and proximate composition of milk. Pediatrics 78, 909-19.

Brown, K.H., A.D. Robertson and N.A. Akhtar (1986b) Lactational capacity of marginally nourished mothers: infants’ milk nutrient consumption and patterns of growth. Pediatrics 78, 920-7.

Burleigh, N. (1991) Watching children starve to death: an exclusive look inside Iraq’s devastated hospitals. Time 10 June, 36-37.

Cameron, M. and Y. Hofvander (1983) Manual on Feeding Znfants and Young Children. Oxford University Press, Oxford.

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Demarchi, M., R. Haider, M. Mohanty, A. Ali, M. Al-Azzawee, S. Al-Saidi and A. Isa (1965) Nutritional status and growth of infants and young children attending MCH centers in Baghdad. Journal of the Faculty of Medicine, Baghdad 7 (1).

de Waal, A. (1989) Famine that Kills: Darfur, Sudan, 1984-85. Clarendon Press, Oxford.

Gounelle, H. and M. Demarchi (1953) Nutritional status of infants and very young children in Baghdad, Iraq. Journal of the Faculty of Medicine, Baghdad 17, 42-53.

Harfouche, J.K. (1982) Breast-feeding Patterns: a review of studies in the Eastern Mediterranean Region. World Health Organization, Geneva.

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Infant Feeding in Emergencies